Provider Demographics
NPI:1871901314
Name:KELLY, MELISSA (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:PRZYBYSZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 STRAWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-2627
Mailing Address - Country:US
Mailing Address - Phone:860-575-2890
Mailing Address - Fax:
Practice Address - Street 1:8 STRAWBERRY LN
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-2627
Practice Address - Country:US
Practice Address - Phone:860-575-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86026739133V00000X
CT1695133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered